No abstract

Hand ischemia following placement of upper limb arteriovenous accesses for dialysis may result in debilitating complications and contribute to morbidity and mortality on dialysis. Two distinct clinical variants of hand ischemia are recognized: vascular steal syndrome, in which a spectrum of severity of ischemic changes affect all tissues of the hand; and ischemic monomelic neuropathy, where ischemia is confined to the nerves of the hand. Early diagnosis and treatment of these complications (often including closure of the access) is imperative to prevent hand paralysis, and digital or hand amputation.

The authors review the literature regarding the effect of education on medical student attitudes toward patient care and toward geriatric patient care in particular. The ability of gerontologic/geriatric programs to foster positive attitudes toward the elderly has been modest. Empathically oriented programs that stress the establishment of contact with healthy, functioning older persons, however, may be twice as effective as cognitively oriented programs that stress the acquisition of technical knowledge. The societal, institutional, and intra/interpersonal forces that work to facilitate or limit the impact of such programs are discussed, and the potential for educational intervention is assessed.

Chronic rejection is the commonest cause of long-term renal allograft loss. Though immunologic factors are thought dominant in its pathogenesis, nonimmunologic factors, in particular, hyperfiltration damage related to reduced renal mass, have also been proposed as factors in the causation of chronic allograft rejection. We assessed the influence of renal size on graft survival and function in all cyclosporine-treated cadaver donor adult renal allograft recipients engrafted at a single center between June 1989 and July 1994, whose grafts functioned for > or = to 3 months (n=169). Patients were divided into 4 groups based on the ratio of kidney volume to recipient body surface area (volume/BSA) (ml/m2), and outcome in groups compared by methods including Cox's proportional hazards and Kaplan-Meier analysis. No significant differences between groups existed for serum creatinine levels, presence of significant proteinuria, or 1- and 5-year graft survival. There was no correlation between volume/BSA and either serum creatinine or degree of proteinuria at 3, 6, 12, 36, and 60 months posttransplant. Volume/BSA was similar in patients with good or poor renal function (58 +/-21 vs. 56 +/- 28 ml/m2), with or without significant proteinuria (57 +/- 24 vs. 60 +/- 25 ml/m2) or in patients who lost their grafts to chronic rejection compared with those with stable allograft function (64 +/- 34 vs. 59 +/- 24 ml/m2). Volume/BSA was not a predictor of graft survival on multivariate regression. We conclude that donor kidney size has no apparent effect on cadaveric renal allograft outcome in the short and intermediate-term, suggesting that close matching of donor kidney size to recipient size is not presently indicated.